Long term prognostic significance of thrombolysis in myocardial infarction risk score after revascularization in non-ST elevation acute coronary syndrome

Background: Non-ST elevation acute coronary syndrome (NSTE-ACS) patients are complex and varied population. Primarily thrombolysis in myocardial infarction (TIMI) risk score was developed to guide therapy and assess the short term (14 days) prognosis of these patients. However, few studies have evaluated the long term prognostic significance of TIMI risk score after revascularization. This study aims at assessing the long term prognostic significance of TIMI risk score, 36 months after revascularization in NSTE-ACS.Methods: This was a retrospective observational cohort study of consecutive NSTE-ACS patients (n=150) treated by percutaneous coronary intervention between January 2017 to June 2017 in a tertiary care center. TIMI risk score was calculated for each patient at admission. The primary endpoint was a composite of MACE (death, repeat target-vessel revascularization, and non-fatal recurrent MI) at the end of 36 months of follow up. Clinical secondary endpoints included the individual components of the primary endpoint, death, nonfatal recurrent MI, and repeat target vessel revascularization.Results: Baseline characteristics for 150 participants were as follows, age 56±9.5 years, 78.7% male, 25% diabetics, 82% hypertensives, and 36% had hypercholesterolemia. The event rates of the primary endpoint and its components after 36 months were 26.6%. Event rates increased significantly as the TIMI risk score increased as determined by regression analysis (p=0.004). The relative risk increased by 66% as the TIMI risk score increased from low risk category (TIMI score 0-2) to high risk (TIMI score 5-6).Conclusions: TIMI risk score can be used for long term prognostication of NSTE-ACS patients after revascularization, and thus can be used by clinicians for therapeutic decision making.

Evaluation of clinical outcome of thrombolytic therapy in elderly patients in Western Rajasthan: a single centre experience

Background: Heart disease is the leading cause of mortality in population above the age of 65 years. Severity and prevalence of coronary artery disease (CAD) increase with increasing age. Thrombolysis remains the standard of care in the management of acute ST-elevation myocardial infarction (STEMI) in developing countries like India where primary percutaneous coronary intervention (PCI) is still not possible in the majority of patients. The risks and benefits of thrombolytic reperfusion therapy among the elderly patients with STEMI is much less known. Authors aimed to evaluate the outcome and complications of thrombolytic therapy in elderly patients admitted with acute STEMI.Methods: The present observational study was done between January 2017 and January 2019 in the department of cardiology, Dr. S.N. Medical College, Jodhpur, India. It included a study group comprising 102 consecutive elderly patients who had acute STEMI and underwent thrombolytic therapy and a control group comprising 102 consecutive elderly patients who had STEMI who were not given thrombolytic therapy. Both groups were evaluated for an outcome (in-hospital mortality) and complications.Results: The overall in-hospital mortality was less in thrombolytic therapy group as compared to control group although not statistically significant (8.82% versus 14.70%, p=0.277). Similarly, in-hospital mortality was less in thrombolytic therapy subgroup A (age 66-74 years) as compared to control subgroup A (6.45% versus 10.75%, p=0.583) and also less in thrombolytic therapy subgroup B (age 75-85years) as compared to control subgroup B (12.50% versus 21.62%, p=0.445).  Among the traditional risk factors, co-morbid conditions and complications, there was less prevalence of diabetes mellitus (4.90% versus 15.68%, p=0.021), hypertension (5.88% versus 6.86%, p=1.000), cardiogenic shock (8.82% versus 9.80%, p=1.000), left ventricular failure (LVF) (0.98% versus 3.92%, p=0.365) and atrioventricular (AV) block (0% versus 4.90%, p=0.245) but more acute kidney injury (AKI) (2.94% versus 0%, p=0.070) in thrombolytic therapy group patients as compared to control group patients.  Cerebrovascular accident (CVA) did not occur in both group patients.Conclusion: Despite the higher prevalence of co-morbidities and high risk features in elderly patients of acute STEMI, timely thrombolysis is beneficial. A mortality benefit was seen in all groups suggesting net benefit regardless of increasing age up to the age of 85 years.

Evaluation of risk factors for antituberculosis treatment induced hepatotoxicity.

Background & objectives: Antituberculosis (anti-TB) drug induced hepatotoxicity (DIH) is the most common side effect leading to interruption of therapy. Wide variations have been found in the reported incidence of hepatotoxicity during short-course chemotherapy. Several risk factors for hepatotoxicity have been suggested in previous studies. We undertook a prospective case-control study to assess the role of these putative risk factors in the development of DIH in patients receiving anti-TB treatment. Methods: One hundred and seventy five consecutive cases with a diagnosis of anti-TB DIH were compared with 428 consecutive controls who took anti-TB drugs for the full duration of chemotherapy without clinical or biochemical evidence of hepatitis. Cases positive for markers of acute viral hepatitis were carefully excluded. Cases and controls were compared with respect to age, sex, site of tuberculosis, radiological extent of disease on chest radiograph, body mass index (BMI), mid-arm circumference (MAC) and liver function at baseline which included serum bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), serum total protein and serum albumin. Results: Univariate logistic regression revealed that the risk of developing DIH was greater in older patients. Significantly greater percentage of cases had extrapulmonary tuberculosis (TB) (P<0.01). Also, a significantly higher percentage of cases had moderate to far advanced disease severity on chest radiograph (P<0.01). On multivariate logistic regression, the adjusted odds were significant (P<0.01) for age >35 yr, MAC <20 cm and hypoalbuminaemia (albumin <3.5 g/dl). Interpretation & conclusions: Older age, poor nutritional status including baseline hypoalbuminaemia were independent predictors of occurrence of anti-TB DIH. Clinicians should be vigilant for occurrence of hepatotoxicity in this high risk group.

Role of acute viral hepatitis as a confounding factor in antituberculosis treatment induced hepatotoxicity.

BACKGROUND & OBJECTIVE: Drug induced hepatotoxicity (DIH) is an important and commonly encountered adverse effect with antituberculosis (anti-TB) treatment. Acute viral hepatitis (AVH) is an important confounding reason which clinically, biochemically and histologically mimics DIH. METHODS: The contributory role of acute viral hepatitis as a confounding factor in patients with normal baseline liver functions who developed acute hepatitis while receiving short-course anti-TB treatment was prospectively studied. The sera of all patients who developed acute hepatitis were analysed for markers for hepatitis A, B, C and E viruses. RESULTS: Viral hepatitis was present in 15 of the 102 (14.7%) patients who developed acute hepatitis while receiving anti-TB treatment with hepatitis E virus being the most common cause Later onset of acute hepatitis [58 (5-133) vs. 26 (3-221) days; P=0.04], large elevations in aspartate aminotransferase (AST) [371 (30-2643) vs. 212 (63-1990 IU/l); P=0.03] and alanine aminotransferase (ALT) [388 (31-2997) vs. 225 (52- 1670 IU/l); P= 0.002] and a longer time for normalization of deranged liver functions [36.7 +/- 13.3 vs. 24.5 +/- 19.3 days; P=0.02] indicated acute viral hepatitis as the cause of liver function derangement. INTERPRETATION & CONCLUSION: Our findings showed AVH in 14.7 per cent patients who developed hepatotoxicity while an anti-TB treatment. Therefore, in endemic areas, viral hepatitis should be sought after and excluded in all patients suspected to have DIH before attributing the hepatotoxic effect to the anti-TB drugs.